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Over two decades into the practice, Dr Azra Ahsan has noticed that many couples, who come seeking obstetric or gynaecological advice, are uncomfortable about telling the exact number of children they have.

When she inquires, it is usually the father who replies, often giving a range and never a definite number. "It is either four or five, six or seven, 11 or 12,” says Azra, who is also technical consultant at the Ministry of Health’s National Committee for Maternal & Neonatal Health (NCMNH). She remarks that “the actual number is normally higher and they are too embarrassed to tell”.

Fathers are sometimes unable to remember their children's name or recall them in a chronological order. "I do not think that men think about the consequences of having unprotected sex. They have it because they have nothing better to do and babies are just a side effect of it," she observes.

Dismal overall

While Pakistan has not had a census since 1998, the estimated population of the country is 193 million according to the United Nations (UN), making it the sixth most populous country in the world. According to Population Reference Bureau, by 2050, Pakistan will climb to fifth on the list, given its population growth rate.

But it seems that the country’s political leaders have yet to comprehend the gravity of the situation. "I have never heard the prime minister or the opposition leaders say that soaring population is a critical issue and that family planning (FP) is a solution," says Dr Farid Midhet, a demographer at the John Hopkins University, affiliated NGO Jhpiego.

"The common man's health, especially women's health, is just not on the government's radar," concedes FP expert Dr Aleya Ali. "We're way behind our target of providing modern contraception methods to 55% of the couples," she points out.

According to the Pakistan Bureau of Statistics, the country's FP score declined by 7.2% in the year 2014-15 compared to the previous year. The score is calculated on the basis of contraceptives sold or distributed free of charge during a period of one year. The score dropped the highest in Punjab (13.4%), followed by Sindh (2.2%), Khyber Pakhtunkhwa (1.2%), and Balochistan (1.3%).

Poor performance or shortage of staff, unavailability of contraceptives and low clientage were to blame for the poor performance in the provinces.

State ineptitude

The responsibility to promote FP comes under the Family Welfare Centres (FWC), but like most government departments, the FWC is underperforming. Dr Aleya points out that that the FWCs work like "government offices from 9am to 2pm and are unable to serve those who may want to come after work".

The Jinnah Postgraduate Medical Centre (JPMC) FWC in Karachi has an 18-member staff, yet they do not make the effort to reach out to their clientele. Dr Azra says that “if they would walk up to the immunisation clinic and the gynecologicals ward within the JPMC premises and counsel the scores of women waiting there, it can make a huge difference".

Some FWCs exist only on paper. In Sindh, for example, there are over 800 FWCs, but most are non-functional, according to Dr Farid.

The FWCs that do receive those seeking assistance, the quality of the counseling is not up to the mark. “It amazes me that my own colleagues are often skeptical of contraceptives for fear of side effects. If they are not completely convinced themselves, how can they advise their patients?” wonders Dr Azra.

Dr Ahsan adds that "there is no proper counselling to prepare women in advance for the minor discomfort they may face at the start of a hormone-based contraceptive method and how to deal with it." The consequence is that women often stop using contraceptives as soon as they experience discomfort. It may also result in women in entire neighbourhoods or villages looking at contraceptives with wariness.

Targeted improvement

However, not everything is dismal. The government is now trying to target the 48% of women who deliver in health facilities and leave without receiving counseling or any family planning services. Majority of these women do not return for postpartum check and often come back with unintended pregnancies.

The program started four years ago and among the contraceptive methods being promoted are implants and intrauterine device (IUD).

“While implants are fairly new in Pakistan, IUDs are not. Implants and IUCDs are categorised as long-acting reversible contraceptives (LARCs); they are safe, long lasting, and discrete. An IUD can last for up to 12 years," informs Dr Ahsan.

"Unlike sterlisation, women can get the device or the implant removed the moment she decides to conceive," Dr Ahsan adds.

23 hospitals in total in Karachi, Lahore, and Islamabad have the skilled staff to provide IUDs. 31, 639 women have consented to this method of contraception over the period of time.

"Antenatal care has increased over the years in Pakistan; more women are now frequenting health facilities for deliveries than they did 20 years back when home births were more common. So health practitioners have this small window of opportunity to provide services," Dr Ahsan says.

"It's the only way to make some headway," says Dr Aleya, who also favours these methods of birth control. "The setting is perfect: the woman is present, the skilled birth attendant is there, as is the contraceptive. The woman just has to give her consent," she adds.

While it is still too early to say what their preferred choice would be, Dr Azra finds that women are becoming accepting of implants as they are not inserted into the uterus, making women less fearful.

But general awareness, as well as affordability, is still the main issue. The implant may cost Rs800 with Rs1,000 as service charges. Many can’t bear this onetime cost. "They spend money on cigarettes daily but refuse to pay for contraceptives," says an irate Dr Azra.

Comments (31) Closed

Hassan (Karachi)Sep 07, 2016 01:12pm

I wholeheartedly agree with the Author. I've heard these tales from my Grandmother who served for a time in KP and Quetta among other places as a Gynecologist.

The only rational I could come up with Pakistan's bizarre need to have more than 2 children is seeing them as commodities who will serve as financial sources in the future. They do not really care what kind of life and upbringing they have, or even if they survive into Adulthood, as there will be more to take their place. Survival of the fittest. The more the merrier.

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wellwisherSep 07, 2016 01:21pm

some one has to take the lead.WHY NOT YOU.China did population control forcibly, India Bangla Desh voluntarily.The programmes are not entirely successful, but hey have an effect.

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Ramesh NakhwaSep 07, 2016 01:23pm

Sad situation this is. In India this was the case one generation back 10 /11 kids per couple. Now clearly its down to one or two and in some cases none by choice. Kids are better educated.

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Riaz MurtazaSep 07, 2016 01:26pm

Family planing is vital for betterment of each family in the country.

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Zafar ShahSep 07, 2016 01:35pm

This population explosion will result in a less previleged people as the wont be able to get the children educated and gainfully employed...unlike parents with say 2 children.
It will also lead to competition over the ever reducing resources...leading to people being left out.
This will ultimately cause large scale social upheaval.

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Fayyaz Ahmad KhanSep 07, 2016 01:40pm

The author has given a good general perspective but the reasons for low rates of contraceptive use are not related to lack of services alone. Pakistan is a very complex society where notions of marriage, family and children are much more powerful than anything else. Unfortunately, these very notions have never been tackled properly by thoroughly understanding the needs of the society. Had supplies been the only problem, the contraceptive inundation scheme tried in the seventies would have been a success. The results and CPR of 70s proved this assumption wrong. Couples need to understand and opt for methods they like rather than accepting those marketed or imposed by government and NGOs. The work therefore needs to be done both on the supply and demand side of the equation if we ever want to make major gains in helping couples make informed decisions about the number and spacing of their children.

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khanSep 07, 2016 01:46pm

we are 11 brothers and sisters, all are either doctors or professors.

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AsadSep 07, 2016 01:50pm

Pakistanis should stop inbreeding, it cause lots of genetic defects and diseases.
stop marrying your cousins people. Inbred, is not good term in civilised society.

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asif khanSep 07, 2016 02:04pm

there could be many root causes of high birth rates in Pakistan and there would be many ways methods and actions that can be proposed and may be one day can be actioned on. The why i see it there are three key areas that can be tackled at indiviual level. 1. religions factor, now as we face high growth risk factor clubed with health of women in general along with health related issues with new borns we need to slowly change the mind set. 2. Child labour, the most lowest from of slavery should be abloshied at every house hold.. period ( we just talk check in your on circle you will find a hipocrate looking at the mirror). 3. education, and not taboo of the subject.

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FaisalSep 07, 2016 02:23pm

Lack of education, resources, frustration leads to the menace of worst planning.

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MudassarSep 07, 2016 02:39pm

@khan You are amongst may be 0 .0001% of the blessed ones who got oppurtunities to get there. Remainings are not getting it.

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JaganSep 07, 2016 03:08pm

Large young population is an asset for any country.
Only need is to provide proper education and opportunities.
Govrenments & Civil society to take lead.

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WTFSep 07, 2016 03:15pm

@khan "we are 11 brothers and sisters, all are either doctors or professors."

You are neither a doctor not a PHD if you are a professor.

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KalimullahSep 07, 2016 03:41pm

@WTF He means they are highly educated and if your are a professor then you must be Master's in any relevant field. First read the post before commenting on it. If his father afford that they i seem no problem in that.

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Fudayl AhmadSep 07, 2016 04:00pm

Population growth is only the number 2 problem. As is clear from some of the comments, overall lack of awareness is our number 1 issue. Situation is improving noticeably and now most educated people try to keep their families small.

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khanmSep 07, 2016 04:28pm

@Fudayl Ahmad... if population is the problem then China should be the worst country in the word.. it is all about the correct use of human resources...

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khanmSep 07, 2016 04:33pm

I think the biggest problem is lack of education and worst entertainment..Give them some thing better to do...By improving health, empowering women, population growth will eventually come down.

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Sajed SyedSep 07, 2016 04:46pm

@asif khan , Bold but succinctly said brother.

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Farooq khan Sep 07, 2016 05:17pm

@khan these are exceptions, and your siblings and parents were successful. You can be proud of this achievement, and rightly so in more ways. But, some one can also say that it was an unintentional selfishness on the part of your parents as one family got hold of limited resources of this land which could have been divided amongst many families.
In any case this kind of family size is unsustainable NOWADAYS, especially in Pakistan.

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dabanggSep 07, 2016 06:35pm

@khan You obviously come from a well to do family. Poor people can not raise 11 kids properly.

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dabanggSep 07, 2016 06:37pm

@khanm China is a lot bigger than PAK.

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dabanggSep 07, 2016 06:39pm

@Jagan True. But having a large population without resources for education is bad. By the time that happens the young population will become old.

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Khalid TorontoSep 07, 2016 06:47pm

Number of children should depend on a couple's financial situation and also if the parents are able to spend time with their kids.

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M.BialSep 07, 2016 06:51pm

Istead of plantation of any device , acknowledge the people about the family planning.If a person can aford to have more than to child , so whats the big deal.

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M.BialSep 07, 2016 06:54pm

Instead of plantation of device acknowledge people about family planning. If a parson can afford 2 to 3 child so what's the big deal.

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TsmilselvanSep 07, 2016 08:35pm

Wow, father does not remember the number of children or their names. How will he call them for dinner,

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Haroon RajaSep 07, 2016 09:13pm

I think everyone is missing the point. It is present Government who has had 3 chances - they have not improved unemployment levels, economy is in taters, corruption is rife, no electricity for the industry etc. With improvements in these sectors, Pakistan would be advancing further. So what are you complaining about? Use your vote and voice in correct manner, speak out.

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ZakSep 07, 2016 09:27pm

@khan this article is about under privileged people who doesn't have enough money to eat better three times a day meal.

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Think LogicalSep 07, 2016 10:23pm

@Kalimullah You are also wrong. Think about the women once who will give birth and raise those kids. Her life will end serving them. And in return do these doctors and professors give the same treatment to her? Why not raise 2 of your own kids and help 10 orphans to become doctor, engineer etc.

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BUBBLESSep 07, 2016 11:49pm

@khan I salute your parents for achieving this difficult task of providing the best education available to all of you. Not all parents are so lucky with their available resources. All they can do is controlling the number of kids to provide get them enrolled in the best schools and colleges which is costlier now a days.

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David SalmonSep 07, 2016 11:51pm

At last, a Pakistani confronts the massive problem of overpopulation. There are now five people in Pakistan where in 1947 there was one. Such huge increases in population eat up every gain the country makes economically. Always, you have to build more dams, import more oil and LNG, construct more roads, pay more for support of the poorest, you name it, you need five times as much of it as you did.

Just making contraceptives widely available would equal the long-term benefit of several dams and power plants.

If more people speak up like the author, the political leaders may discover some courage in themselves.